Worker’s compensation and automobile no-fault claims involving prescription drugs inherently contain several challenges for insurance companies. There are many ways to address these challenges, but the most effective involves a partnership between insurance companies and pharmacy benefit managers (PBM). This article will cover the top five reasons that PBMs work better than other options.
The first reason involves a significant impact on adjusters’ and examiners’ time. Experienced pharmacy benefit managers will be able to greatly reduce the administrative burden for adjusters and examiners by acting as a third-party administrator (TPA) of claims. By providing coordination of benefits with a claimants’ primary health insurance for auto no-fault benefits, a TPA allows adjusters and examiners to focus on adjudicating their claims efficiently and productively, eliminating the need for adjusters and examiners to spend their time on coordination of benefits related to copays and deductibles for auto no-fault benefits.
Secondly, a PBM will have negotiated discounted rates on pharmaceutical services for an insurance company and its claimants. These discounted rates are offered through a network of quality pharmaceutical service providers that an insurance company’s claimants have access to for all claim-related prescriptions.
Third, pharmacy benefit managers will be able to readily identify the appropriateness of prescriptions for an insurance company’s claimants. A pre-authorization process allows the PBM to ensure that all prescriptions being billed under a claim are directly related to that claim; once assured of injury relatedness, the claimant will pay no out-of-pocket cost for his or her prescription. Additionally, the PBM will identify the medical necessity of a dispense as written (DAW) drug and whether a generic drug is available and appropriate to substitute for the claimant.
The fourth reason a PBM is the best option for claims involving prescription drugs concerns the issue of compound medication billing. Pharmacies that are set-up to mix ingredients of medications that are customized for a specific patient are called compounding pharmacies. Compound medications are adjudicated differently since multiple medications are used in a recipe or formula in the compounded medication along with specialized equipment and pharmacy labor costs. Northwood processes claims according to a proprietary fee schedule in order to avoid unnecessarily high costs to the insurance company.
Finally, a PBM typically offers additional benefits to increase claimant satisfaction as well, such as home delivery services for prescriptions. If a claimant sustained catastrophic injuries while on the job or in an automobile accident and is unable to pick up his or her own prescriptions, a PBM will allow the appropriate prescriptions to be delivered directly to the claimant. This ensures the claimant access to the necessary medicine and increases claimant satisfaction with the insurance company.
These are but a sampling of reasons why a PBM works best for an insurance company administering workers’ compensation or automobile no-fault claims. Northwood has over 20 years of experience as a PBM and offers these benefits along with many more. If you have questions about the available benefits Northwood can offer to your company, please contact us at your convenience.
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